Alternative medicine and breast cancer

After the three posts that I recently did about vaccination have garnered well over 250 comments between the three of them (and still counting), I thought it might be time to switch topics. As important as they are, I don’t want this blog to become all vaccines all the time. (After all, look what happened to the blog SupportVaccination.org. It’s a long story that I’ll have to tell you sometime; but suffice it to say that the blog no longer exists.) Quite frankly, seeing the same old fallacies being repeated over and over again by antivaxers does get tiresome after a while. After all, how many times can you rebut the same things over and over again?

Wait a minute.

Isn’t that what I do on this blog (rebut the same fallacies over and over and over again), be they claims from creationists, alties, or Holocaust deniers?

Never mind. Rebutting the same logical fallacies over and over again seems to be the lot of a skeptic. It’s what I do on this blog. Keep reading, and I’ll try to continue to make it entertaining.

Fortunately for your (and my) edification, there recently appeared in the American Journal of Surgery a paper that actually looks at what happens to women who decide to opt for “alternative” therapy rather than conventional therapy. Given my specialty and interest in evidence-based medicine and applying EBM to “alternative” therapies, I’d be truly remiss if I didn’t comment. So here we go, and here’s the paper:

Chang et al (2006). Outcomes of breast cancer in patients who use alternative therapies as primary treatment. Am. J. Surg. 192:471-473.

Here’s the abstract:

BACKGROUND: Some breast cancer patients opt for alternative treatments in place of conventional treatments. The lack of published data on the outcome of this strategy may contribute to this trend. METHODS: A chart review was performed of breast cancer patients who refused or delayed standard surgery, chemotherapy, and/or radiation therapy. Prognosis was calculated for recommended and actual therapy. RESULTS: Thirty-three patients were included in the analysis. Of 11 patients who initially refused surgery, 10 developed disease progression. Of 3 patients who refused adequate nodal sampling, 1 developed nodal recurrence. Of 10 patients who refused local control procedures, 2 developed local recurrences and 2 died of metastatic disease. By refusing chemotherapy, 9 patients increased their estimated 10-year mortality rate from 17% to 25%. CONCLUSIONS: Alternative therapies used as primary treatment for breast cancer are associated with increased recurrence and death. Homeopathy instead of surgery resulted in disease progression in most patients. These data may aid patients who are considering alternative therapies.

This study is interesting to me because it’s the first one that I can recall that has explicitly looked at the outcomes of patients who chose “alternative” therapies as their primary treatment. There are lots of studies out there looking at alternative medicine use in cancer patients, but these mainly look at patients who use it in addition to conventional therapy (i.e., as “complementary” therapy). It’s rare for a study to look at outcomes in patients using alternative medicine as their primary treatment. Because this is a retrospective study, it’s not without its flaws, but, because it would be highly unethical to do a randomized, double-blinded trial looking at this question, retrospective studies are the best we can do, even with their flaws. This study does have one strength, though, compared to most such studies, and that it the patient population. It comes from a community practice, not an academic medical center. Consequently, it can be viewed as more representative of the “real” world situation than many studies done in academic medical centers, where the patient population may be self-selected as people as either motivated enough to seek out tertiary care centers or sick enough that their community surgeons and oncologists refer them.

One thing that is rather fascinating is the variety of alternative therapies that the study population opted for, including coral calcium, coenzyme Q10, herbs, dietary therapy, high dose vitamins, mushrooms, chelation therapy, poison hemlock (I’m still scratching my head over that one, particularly given how alties so frequently lambaste chemotherapy as “poison”), and a variety of unspecified therapies. At least there were no examples of coffee enemas that I could see. In any case, because of the sheer variety of therapies used and the low number of patients using each individual one that, as the authors put it, it was not possible to “identify particular alternative modalities that were particularly ineffective.”

Who says scientific papers don’t occasionally have sarcasm in them?

Basically, the study identified 47 breast cancer patients who opted for alternative therapy, but followup information was only available for 33. These were divided into patients who refused surgical treatment altogether; patients who delayed appropriate surgical treatment to pursue alternative treatments; patients who refused adequate sampling of the lymph nodes; patients who refused procedures to ensure adequate local control (additional surgery and/or radiation therapy); and patients who refused chemotherapy. I’m going to concentrate on patients who refused or delayed surgery.

Of patients who refused surgery, none of the six patients identified were Stage IV (metastatic disease) at initial diagnosis. However, five out of these six patients who returned to the surgeons doing the study had progressed to stage IV, with a median time of followup of 14 months, with one death within a year. That’s pretty amazing, given that two of these patients were Stage I upon initial presentation. There were also five patients identified who initially refused surgery in favor of alternative medicine, all of whom were Stage II or III. The median time between diagnosis and surgery was 37 months. All five demonstrated progression of their disease, with three progressing to Stage IV disease and one of these dying of metastatic disease. Thus, 10/11 patients who refused surgery experienced significant disease progression.

Not surprisingly, patients who declined chemotherapy or hormonal therapy fared better because, as I’ve explained before, for operable breast cancer, the single most efficacious intervention is surgery, and it is not that uncommon for patients with even fairly large tumors to be “cured” with surgery alone. Indeed, as I discussed before, the benefits of chemotherapy are fairly modest in many cases. In a small number of patients, it was difficult to quantify the effect of choosing alternative medicine over conventional chemotherapy, but the authors were able to estimate that the relative risk of death in 10 years in those who refused chemotherapy was 1.54; i.e., a 54% higher chance of dying within 10 years compared to those treated with conventional medicine.

As a retrospective study, this study has several flaws, mainly the inability to compare directly a group treated with only alternative medicine with a group treated with conventional medicine. But, because it would be unethical to try to do a randomized study on this issue because of concerns over observing patients falling below the standard of care (as the authors put it), retrospective studies are the best we’ll be able to do for now. What will be needed are studies looking at larger numbers of patients, particularly so that associations can be inferred about which particular forms of alternative therapy are associated with worse outcomes than others. From my perspective, the reason for worse outcomes in patients who choose alternative medicine over conventional is almost certainly from the delay in treatment. In other words, my best guess is that most alternative therapies are probably not causing a worse outcome (although it’s possible that some are, due to toxicity), but rather are simply ineffective, allowing the cancer to progress in essence untreated.

It’s also important to point out that, among cancers, breast cancer tends to be one of the slower-growing, and therefore more forgiving–not always, but usually. Delays in treatment of a few weeks usually don’t make much, if any difference, in outcome. If it were otherwise, doing immediate reconstruction would be more difficult because the time constraints in coordinating the schedules of the breast surgeon and the plastic surgeon would be much more tight. Consequently, seeing such a decrease in survival in the patients who opted for alternative therapy, particularly such that it is so obvious in even small numbers of patients, suggests that the alternative therapies used by patients in this study are at best worthless and at worst harmful. Moreover, it suggests to me that the results of reliance on such unproven treatments for more aggressive cancers would be even more potentially disastrous. My hope is that this study (1) serves as a warning to breast cancer patients considering opting for alternative therapies in preference to conventional therapy and (2) spurs more research in this area to identify which therapies may actually be worse than useless.